2021 JFS Financial Assistance Application

The Jewish Federation of Omaha is charged with administering the allocation and distribution of financial assistance funds entrusted to the community for the benefit of Omaha's Jewish community. This duty includes the guarantee of confidentiality to the applicants and their families in conjunction with the diligent stewardship of community funds. On an annual basis, the community allocates dollars for financial assistance. Award decisions are based on the financial need of applicants, the number of requests, and the amount of funds available. All financial aid awards require an annual application. THE CURRENT YEAR APPLICATION

To apply for Jewish Family Service financial assistance or reduced Jewish Community Center membership fees, please complete the attached application. Along with the application please use the checklist on page 2 to ensure you have attached all required documentation. Any missing information will delay the application process and the ability to make a decision on your behalf. Your completed application and all documentation is then to be placed in a secure envelope. Your application should then be submitted to Linda Cogen c/o Jewish Family Service and can be submitted at any time throughout the year. Applications for reduced JCCmembership fees for current JCC members should be submitted by January 1, 2022. Information is reviewed by the Financial Assistance Council and assistance will be determined within two weeks of receipt of complete information. You will receive notification in the mail of an award or denial. If you have any questions regarding this application and reduced JCC membership or JFS assistance, please contact Linda Cogen at (402)334-6493 or lcogen@jfsomaha.com.

Funding for financial aid is provided through the Annual Campaign of the Jewish Federation of Omaha, endowment funds of the Jewish Federation of Omaha Foundation and other grant entities.

Select which one applies to you:

Young Adult (age 13-30) Individual (age 31-69) Couple (2 adults living at the same residence) Family (2 adults and dependent children under age 25 at the same residence) Single Parent Family (Unmarried parent with dependent children under age 25 at the same residence) Senior Individual (age 70 and over) Senior Couple (2 spouses with one or both at the age 70 or over)

Total amount of assistance requested:

Please list, in detail, any sources of financial assistance for which you have applied and indicate any amount for which you have been approved or have pending.

0/350

Amount of assistance requested

Emergency Contact name and relationship *

Emergency Contact phone number *

A copy of your most recent Federal Tax Return, Form 1040. Two most recent paystubs for each adult/parent listed on the application. A copy of your most recent quarterly statement from any other source of income, including but not limited to 529 Plan, IRA, Social Security, mutual fund, etc. Most recent billing statement of each expense listed on pages 5 and 6 (i.e., MUD, OPPD, insurance, cable, phone, car payments, mortgage/rent, credit card statement(s), etc.) Documentation from other sources of financial aid (i.e., synagogue, family, etc.)

Please upload ALL documents listed above: *

Please select: *

New Application Renewal Application

NAME *

EMAIL

example@example.com

ADDRESS *

CITY *

STATE *

ZIP CODE *

HOME PHONE

CELL PHONE *

WORK PHONE

AGE *

GENDER *

DATE OF BIRTH *

Date

STATUS

Married Divorced Single Widowed

Are you a member of the Jewish Community? *

Yes, I am Jewish No, I am not Jewish

Synagogue Affiliation *

NAME

EMAIL

example@example.com

HOME PHONE

CELL PHONE

WORK PHONE

ADDRESS

CITY

STATE

ZIP CODE

AGE

GENDER

DATE OF BIRTH

Date

STATUS

Married Divorced Single Widowed

Are you a member of the Jewish Community?

Yes, I am Jewish No, I am not Jewish

Synagogue Affiliation

NAME

DOB

NAME

DOB

NAME

DOB

NAME

DOB

I attest that the foregoing information is true and correct. I understand that knowingly providing false information will deem me ineligible to receive assistance from The Jewish Federation of Omaha and its agencies.

APPLICANT SIGNATURE *

Clear

DATE

Date

SPOUSE SIGNATURE

Clear

DATE

Date

Are you employed? *

Yes No Part-time Full-time

NAME OF EMPLOYER

Wages Earned (Monthly)

Is your spouse employed?

Yes No Part-time Full-time

NAME OF EMPLOYER

Wages Earned (Monthly)

Do you receive any of the following sources of income? State monthly amount received.

Social Security

Child Support

SSI

Alimony

State Assistance: SNAP, Title XX, Section 8, Medicaid, etc.

Business Income*

Unemployment

Capital Gains*

Checking/Savings

Real Estate*

Veteran Benefits

Assistance from relatives/friends

Stocks/Mutual Funds/Bonds

Other

* If income is listed from business, capital gains, real estate or other, provide description and additional details in box below:

Total Monthly Income *

Total Yearly Income

ADJUSTED GROSS INCOME (as listed on your Federal Tax Return)

Household Expenses (list monthly expenses)

Mortgage/Rent *

Cable

Food *

Electric *

Gas

Water/Sewer

Trash

Phone

Internet

Taxes (if not included with mortgage payment)

Subtotal (household expenses)

Automobile (list monthly expenses)

Number of Cars *

Model(s) *

Loan(s)

Maintenance/ Repair

Gasoline

Subtotal (automobile expenses)

Insurance (list monthly expenses)

Auto

Life

Health

Homeowners/renter (if not included in mortgage payment)

Subtotal (insurance expenses)

Health (list monthly expenses)

Doctor

Dentist

Vision

Medication

Subtotal (health expenses)

Dues (list monthly expenses)

Synagogue/Temple

JCC Membership

Professional

Subtotal (dues expenses)

Fixed Debt with Interest (list monthly expenses)

Credit Cards

Charge Accounts

Legal Obligations

Loans

Other

Subtotal (fixed debt with interest)

Child(ren) (list monthly expenses)

Preschool

Private Education

Daycare

College

Subtotal (child expenses)

Miscellaneous (list monthly expenses)

Cleaning Service

Vacations

Alimony Paid

Child Support

Retirement

Savings

Nursing Home

Other

Subtotal (miscellaneous expenses)

SUBTOTAL SUMMARY

Please refer back to your entries and enter each category's monthly expense total in dollar ammounts. Use 0 instead of N/A when the expense category doesn't apply to you.

Household *

Automobile *

Insurance *

Health *

Dues *

Fixed Debt *

Child(ren) *

Miscellaneous *

TOTAL MONTHLY HOUSEHOLD EXPENSES: *

If your monthly expenses exceed your monthly income, please explain how you are meeting the shortfall, i.e. assistance from relatives, credit card debt, etc. *

0/500

Please explain in detail the financial circumstances that you feel should be considered as your request is reviewed. You may include, but are not limited to, detailing the following: parents and/or siblings attending college; support of family member(s) outside of the immediate family; excessive educational debt; excessive medical debt; serious medical issues affecting the family; significant loss of income in the past year; single parent with little or no income from absent parent, etc. Providing the most complete information will enable the timeliest consideration of your application. *

0/1000

Briefly describe your household's involvement in the Jewish community. *

Application for Financial Assistance

Please complete the section(s) for which you are requesting financial assistance

Requesting assistance for Jewish Community Center Membership

Requesting Jewish Family Service Financial Assistance:

DOCUMENT CHECKLIST:

PERSONAL INFORMATION

Applicant/Legal Guardian Information

Spouse Information

Children in the household

INCOME INFORMATION

EXPENSE INFORMATION